C. van der Starre (Cynthia)http://repub.eur.nl/ppl/23280/
List of Publicationsenhttp://repub.eur.nl/eur_signature.pnghttp://repub.eur.nl/
RePub, Erasmus University RepositoryPaediatric critical incident analysis: lessons learnt on analysis, recommendations and implementationhttp://repub.eur.nl/pub/70531/
Sat, 31 May 2014 00:00:01 GMT<div>C. van der Starre</div><div>M. van Dijk</div><div>A. van den Bos</div><div>D. Tibboel</div>
The objectives of this study were to identify causal and contributing factors of serious patient safety incidents in a paediatric university hospital, to report on ensuing recommendations and to assess the extent of implementation of the recommendations. The possible causal and contributing factors identified in 17 incidents were classified by a system devised by Vincent et al. Proposed recommendations were classified by the same system, and degrees of implementation were established. A median of 5 causal and contributing factors per incident were identified. Twenty-two percent of all factors were related to teamwork and 22 % to task factors. A median of 5 recommendations per analysis were formulated. Most recommendations were related to task factors (36 %). The time load of each analysis was a mean of 27 h. One third of the recommendations have been acted upon, mostly those related to task and team factors. Conclusion: Incident analysis is time-consuming but yields indispensable information on causal and contributing factors, presenting numerous opportunities for quality improvement. The value of these analyses could be improved by appointing responsibilities and setting up time frames for implementation. A bottom-up approach with managerial support appears to be a key to turning incident analysis and quality improvement into an ongoing process.Patient safety in South Africa: PICU adverse event registrationhttp://repub.eur.nl/pub/72757/
Wed, 01 Jan 2014 00:00:01 GMT<div>J.M. Vermeulen</div><div>M. van Dijk</div><div>C. van der Starre</div><div>R.M. Wösten-van Asperen</div><div>A. Argent</div>
OBJECTIVE:: Adverse event registration is a means to improve patient safety in a PICU. So far it has been used in European and North American countries mainly. We studied adverse events in a South African setting with the aims to 1) assess rates and types of adverse events with two different registration methods and 2) describe characteristics of patients experiencing adverse events. DESIGN:: This study consisted of 1) a retrospective audit of randomly selected patient records and 2) a prospective observational study of real-time registration of AEs during ward rounds. Adverse events were identified using the Child Health Corporation of America - Pediatric Pharmacy Advocacy Group PICU trigger tool. SETTING:: A multidisciplinary 20 bed PICU at the Red Cross War Memorial Children's Hospital in Cape Town. PATIENTS:: The retrospective section of the study involved 80 randomly selected patients who had been discharged from the PICU, and the prospective study involved patients who were present in the PICU between March and June 2012. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: The retrospective audit identified 260 adverse events in 61 patients (50.8 per 100 patient days). Nineteen patients (24%) did not have any adverse events. Catheter complications, hypoglycemia, and endotracheal tube malpositioning requiring repositioning were most frequent. Prospective registration during 58 ward rounds revealed 272 adverse events in 236 patients (27.2 per 100 patient days), particularly catheter complications, nosocomial infection, and surgical complications. Hundred thirty-two patients of the total 236 patients (56%) did not experience an adverse event. Patients experiencing adverse events underwent mechanical ventilation significantly more frequently. Length of stay was significantly associated with number of adverse events. CONCLUSIONS:: The trigger tool method identifies a higher adverse event rate compared with real-time registration. Each method has a unique contribution to yield types of adverse events. CopyrightImplementation of a children's hospital-wide central venous catheter insertion and maintenance bundlehttp://repub.eur.nl/pub/70902/
Wed, 16 Oct 2013 00:00:01 GMT<div>K. Helder MScN</div><div>R.F. Kornelisse</div><div>C. van der Starre</div><div>D. Tibboel</div><div>C.W.N. Looman</div><div>R.M.H. Wijnen</div><div>M.J. Poley</div><div>E. Ista</div>
Background: Central venous catheter-associated bloodstream infections in children are an increasingly recognized serious safety problem worldwide, but are often preventable. Central venous catheter bundles have proved effective to prevent such infections. Successful implementation requires changes in the hospital system as well as in healthcare professionals' behaviour. The aim of the study is to evaluate process and outcome of implementation of a state-of-the-art central venous catheter insertion and maintenance bundle in a large university children's hospital. Methods/design. An interrupted time series design will be used; the study will encompass all children who need a central venous catheter. New state-of-the-art central venous catheter bundles will be developed. The Pronovost-model will guide the implementation process. We developed a tailored multifaceted implementation strategy consisting of reminders, feedback, management support, local opinion leaders, and education. Primary outcome measure is the number of catheter-associated infections per 1000 line-days. The process outcome is degree of adherence to use of these central venous catheter bundles is the secondary outcome. A cost-effectiveness analysis is part of the study. Outcomes will be monitored during three periods: baseline, pre-intervention, and post-intervention for over 48 months. Discussion. This model-based implementation strategy will reveal the challenges of implementing a hospital-wide safety program. This work will add to the body of knowledge in the field of implementation. We postulate that healthcare workers' willingness to shift from providing habitual care to state-of-the-art care may reflect the need for consistent care improvement. Trial registration: Dutch trials registry, trial # 3635. Trial registration. Dutch trials registry (), trial # 3635.Nursing protocol violations: Detect, correct and communicatehttp://repub.eur.nl/pub/66064/
Fri, 01 Mar 2013 00:00:01 GMT<div>H. te Beest</div><div>C. van der Starre</div><div>D. Tibboel</div><div>M. van Dijk</div>
Aims and objectives: The Critical Nursing Situation Index (CNSI) is a checklist to detect nursing protocol violations. The objectives of this study were to determine incidences and severities of nursing protocol violations and to check whether corrective actions were taken. Design: Prospective observational audit. Methods: This study was performed in the Intensive Care Unit of the Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands. The CNSI was applied in the period February 2009 to February 2010 by 14 purpose-trained nurses whose interrater reliability had proved sufficient. The checklist addressed nine domains of nursing care: Basic care, Circulation, Respiration, Digestive tract, Infection, Invasive catheters, Medication, ECMO and Central nervous system. The trained nurses also recorded whether violations were discussed with the bedside nurse, whether they could be corrected; and whether they were justifiable. Protocol violations are justifiable when protocol adherence carries greater risk of harm to the patient. Results: Protocol violations were identified for 987 of 8107 items (12·2%) checked in 238 observations in 126 patients. The percentage of protocol violations varied from 5% in the Medication domain to 26% in the Digestive tract domain. More than fifty percent (53·4%) of all protocol violations were corrected in the same shift; 22·3% of all protocol violations proved justifiable, however, these were rarely documented (6·4% of cases). Nurses' classification of the severity of the protocol violations was not reliable because linearly weighted kappa varied from 0 to 0·33. Conclusions: The CNSI is a useful tool to monitor and correct nursing protocol violations. Relevance to clinical practice: Timely identification and correction of protocol violations will reduce possible adverse events resulting from these violations. Furthermore, this study made us aware that protocol violations may be justifiable in clinical practice provided they are well documented.Safety of routine early MRI in preterm infantshttp://repub.eur.nl/pub/61779/
Mon, 01 Oct 2012 00:00:01 GMT<div>A. Plaisier</div><div>M.M.A. Raets</div><div>C. van der Starre</div><div>M. Feijen-Roon</div><div>P. Govaert</div><div>M.H. Lequin</div><div>A.M. Heemskerk</div><div>J. Dudink</div>
Background: Cerebral MRI performed on preterm infants at term-equivalent 30 weeks' gestational age (GA) is increasingly performed as part of standard clinical care. Objective: We evaluated safety of these earlyMRI procedures. Materials and methods We retrospectively collected data on patient safety of preterm infants who underwent early MRI scans. Data were collected at fixed times before and after the MRI scan. MRI procedures were carried out according to a comprehensive guideline. Results: A total of 52 infants underwent an MRI scan at 30 weeks' GA. Although no serious adverse events occurred and vital parameters remained stable during the procedure, minor adverse events were encountered in 26 infants (50%). The MRI was terminated in three infants (5.8%) because of respiratory instability. Increased respiratory support within 24 h after the MRI was necessary for 12 infants (23.1%) and was significantly associated with GA, birth weight and the mode of respiratory support. Hypothermia (core temperature < 36°C) occurred in nine infants (17.3%). Temperature dropped significantly after the MRI scan. Conclusion: Minor adverse events after MRI procedures at 30 weeks GA were common and should not be underestimated. A dedicated and comprehensive guideline for MRI procedures in preterm infants is essential.Real-time registration of adverse events in Dutch hospitalized children in general pediatric units: First experienceshttp://repub.eur.nl/pub/68752/
Thu, 01 Mar 2012 00:00:01 GMT<div>C. van der Starre</div><div>M. van Dijk</div><div>D. Tibboel</div>
The objectives of this study are to describe the number and nature of adverse events occurring in general pediatric practice, to describe factors contributing to the occurrence of these adverse events, and to report on the experience of pediatricians with reporting adverse events. It is a prospective study on 11 pediatric units in a 3-month period; adverse events were registered for all newly admitted patients. Ninety-four adverse events were registered in 88 of 5,669 patients, amounting to a 1.6 per 100 admissions rate and a 0.4 per 100 patient days rate. Ninety percent of the adverse events did not cause serious harm. Failed diagnostic procedures were most common. Conclusion: Adverse event registration in general pediatric practice is a first step in assessing quality and safety of care. It yields a considerable number of adverse events. Compliance to adverse event registration in daily practice is difficult but also key to optimal monitoring of quality of care.Eosinophilic myenteric ganglionitis as a cause of chronic intestinal pseudo-obstructionhttp://repub.eur.nl/pub/37190/
Sun, 01 Jan 2012 00:00:01 GMT<div>A.H.A.G. Ooms</div><div>J.B. Verheij</div><div>J.M. Hulst</div><div>J. Vlot</div><div>C. van der Starre</div><div>L. de Ridder</div><div>R.R. de Krijger</div>
Patient Safety in Pediatrics: a Developing Disciplinehttp://repub.eur.nl/pub/76038/
Thu, 03 Nov 2011 00:00:01 GMT<div>C. van der Starre</div>
__Abstract__
The publication of the breakthrough report “To Err is Human” by the Institute of Medicine was the
launch of patient safety initiatives all over the world. In the intensive care unit (ICU) of the Erasmus
MC-Sophia Children’s Hospital this resulted in the institution of a multimodal patient safety management
system under the name Safety First in 2005. This system now includes nine major elements,
representing monitoring and intervention activities. In this thesis we report on the results and the
implementation of the patient safety management system called Safety First.
__Outline of this thesis:__
In part I the concept of patient safety and the Safety First project are introduced. The rationale for
selecting the elements of the patient safety management system is explained. As preventable mortality
and morbidity are the public focus as outcome parameters for quality and safety of care, we
have studied very long stay patients in our ICU (chapter 2). The goal of this study was to determine
characteristics and mortality in these patients as well as modes of death. Chapter 3 presents an evaluation
of potentially preventable deaths in our ICU. An important question was whether five years
of patient safety efforts had resulted in fewer potentially preventable deaths.
Part II reflects on the difficulties in monitoring adverse events. In chapter 4 we present numbers and
types of adverse events identified with real time physicians’ registration during a 3-month period in
general pediatric practice. The next chapter is a study into adverse events in the surgical pediatric
ICU in a 2-year period. We combined the physicians’ registration with the Trigger Tool methodology
as developed by the Institute for Healthcare, Boston, USA. The goals were to determine the rate and
nature of the adverse events and to compare the two methods.
In part III a number of elements of Safety First are described, as well as other studies into patient
safety issues relevant to bedside ICU care. Chapter 6 brings the results of critical incident analysis
with a focus on the factors contributing to the incident and the resultant recommendations. The
next study evaluated the availability and reliability of drug formularies used in our ICU, which are
crucial in safe drug prescription. In chapter 8 we discuss the safety of routine MRI scans in preterm
infants at 30 weeks gestational age, as reflected by safety incidents and adverse events. In the next
chapter, safety focused Mortality and Morbidity conference reports were scrutinized for numbers
and types of recommendations stemming from these meetings. Chapter 10 is a study about nursing
protocol violations established with the Critical Nursing Situation Index.
Part IV describes a study of safety culture in the ICU, as it emerged from a safety attitude questionnaire
administered to all staff. We aimed to compare findings to benchmark data and explore any
deficiencies.
In the general discussion in part V the results of the studies are commented on and future directions
are given, including guidelines for optimal implementation of a patient safety management system
and future benchmarking.Patient safety culture in a Dutch pediatric surgical intensive care unit: An evaluation using the Safety Attitudes Questionnairehttp://repub.eur.nl/pub/34436/
Tue, 01 Nov 2011 00:00:01 GMT<div>M.J. Poley</div><div>C. van der Starre</div><div>A. van den Bos</div><div>M. van Dijk</div><div>D. Tibboel</div>
Objective: Nowadays, the belief is widespread that a safety culture is crucial to achieving patient safety, yet there has been virtually no analysis of the safety culture in pediatric hospital settings so far. Our aim was to measure the safety climate in our unit, compare it with benchmarking data, and identify potential deficiencies. Design: Prospective longitudinal survey study at two points in time. Setting: Pediatric surgical intensive care unit at a Dutch university hospital. Subjects: All unit personnel. Interventions: To measure the safety climate, the Safety Attitudes Questionnaire was administered to physicians, nurses, nursing assistants, pharmacists, technicians, and ward clerks in both May 2006 and May 2007. This questionnaire assesses caregiver attitudes through use of the six following scales: teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions, and stress recognition. Earlier research showed that the Safety Attitudes Questionnaire has good psychometric properties and produced benchmarking data that can be used to evaluate strengths and weaknesses in a given clinical unit against peers. Measurements and Main Results: The response rates for the Safety Attitudes Questionnaire were 85% (May 2006) and 74% (May 2007). There were mixed findings regarding the difference between physicians and nurses: on three scales (i.e., teamwork climate, safety climate, and stress recognition), physicians scored better than nurses at both points in time. On another two scales (i.e., perceptions of management and working conditions), nurses consistently had higher mean scale scores. Probably due to the small number of physicians, only some of these differences between physicians and nurses reached the level of statistical significance. Compared to benchmarking data, scores on perceptions of management were higher than expected (p < .01), whereas scores on stress recognition were low (p < .001). The scores on the other scales were somewhat above (job satisfaction), close to (teamwork climate, safety climate), or somewhat below (working conditions) what was expected on the basis of benchmarking data, but no persistent significant differences were observed on these scales. Conclusions: Although on most domains the safety culture in our unit was good when compared to benchmark data, there is still room for improvement. This requires us to continue working on interventions intended to improve the safety culture, including crew resource management training, safety briefings, and senior executive walk rounds. More research is needed into the impact of creating a safety culture on patient outcomes. Evaluation of drug formularies for pediatric intensive carehttp://repub.eur.nl/pub/31725/
Sat, 01 Jan 2011 00:00:01 GMT<div>I. Ceelie</div><div>C. van der Starre</div><div>D. Tibboel</div><div>K. Stol</div><div>G. Koren</div><div>S.N. de Wildt</div>
Objectives: To evaluate availability and reliability of pediatric drug dosing guidelines in selected formularies for intensive care patients. Most drugs used in the pediatric intensive care unit are prescribed off-label, often on the guidance of limited information from commonly used drug formularies. Design: Availability of dosing information on prescribed drugs in a Dutch intensive care unit from January 1, 2005 to December 31, 2006 was compared among four selected formularies (Micromedex, Lexi-Comp, Drug Formulary for Children, Drug Doses). Reliability of dosing guidelines was assessed by evaluating labeling status and literature data for the three most (midazolam, acetaminophen, and amoxicillin/clavulanic acid) and the three least (bosentan, ketanserin, and iloprost) prescribed drugs. Measurements and Main Results: The selected formularies covered 68% to 86% of all 257 prescribed drugs. Guidelines differ widely on daily doses per kilogram, dose description, dosing regimen, and age ranges. For the three most prescribed and one of the least prescribed drugs (bosentan), dosing guidelines adequately reflected labeling status and existing (but scarce) literature. No dosing guidelines were available for iloprost, and only one dosing guideline was available for ketanserin. Conclusions: This study shows that four commonly used drug formularies give few and widely differing dosing guidelines for drugs prescribed in the intensive care unit. If guidelines exist, they seem to reflect labeling status (if present) and limited literature available. Findings from this study likely reflect the scarcity of drug studies in this population. Physicians should be aware of the limitations of these formularies for daily practice in this group of vulnerable patients. Copyright Mortality in very long-stay pediatric intensive care unit patients and incidence of withdrawal of treatmenthttp://repub.eur.nl/pub/19549/
Fri, 01 Jan 2010 00:00:01 GMT<div>S. Naghib</div><div>C. van der Starre</div><div>S.J. Gischler</div><div>K.F.M. Joosten</div><div>D. Tibboel</div>
Background: The mortality for children with prolonged stay in pediatric intensive care units (PICU) is much higher than overall mortality. The incidence of withdrawal or limitation of therapy in this group is unknown. Purpose: To assess mortality and characteristics of children admitted for ≥28 days to our ICU, and to describe the extent to which limitations of care were involved in the terminal phase preceding death. Methods: For the period 2003 to 2005 clinical data were collected retrospectively for children with prolonged stay (defined as ≥28 days) in a medical/surgical PICU of a university children's hospital. Results: In the PICU, 4.4% of the children (116/2,607, equal gender, mean age 29 days) had a prolonged stay. Median (range) stay was 56 (28-546) days. These children accounted for 3% of total admissions and occupied 63% of total admission days. Mortality during admission for this group was five times higher (22%) than the average PICU mortality rate of 4.6%. Withdrawal or limitation of therapy preceded 70% of deaths. Conclusions: Children with prolonged stay in the PICU have a significantly high risk of mortality. Death is typically preceded by limitation of care.